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Extreme Men’s Fellowship Waiver Form

Name of Child or Adult Participant (please print) ___________________________________ Parent(s) and/or legal guardian(s) if child participant _______________________________ Address _____________________________________________________

CityStateZip

Home Phone (______) _______________________ Work Phone (______) ___________________________ Age of Child ___________________ Birth Date ____________________ Academic Grade ______________

Functions and Activities

It is my understanding that participating in the programs and recreational and other activitiesof The Salvation Army is a privilege. Prior to my participation in such activities, Iacknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due totransportation-related accidents, illness, or even death. In addition, I acknowledge that theremay be other risks inherent in these activities of which I may not be presently aware.

Release of Liability

By signing this Permission/Waiver Form, I expressly warrant that the child named above or I(if I am a participant) am capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or meparticipating in the activities, whether such risks are known or unknown to me at this time. Ifurther release

The Salvation Army and its staff, volunteers, and agents from any claim thatmy child may have or that I may have against them as a result of injury or illness incurredduring the course of participation in the activities. This release of liability shall include(without limitation) any claims of negligence or breach of warranty. This release of liability isalso intended to cover all claims that members of the child’s or my family or estate, heirs,

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representatives, or assigns may have against The Salvation Army or its staff, volunteers, or agents.I further agree to indemnify and hold harmless

The Salvation Army and its staff volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above or I, if I am aparticipant, may be in need of first aid or emergency medical treatment as a result of anaccident, illness, or other health condition or injury. I do hereby give permission for agents of The Salvation Army to seek and secure any needed medical attention or treatment for thechild named above or me, if I am a participant, including hospitalization if in the agent’sopinion such need arises. In doing so, I agree to pay all fees and costs arising from thisaction to obtain medical treatment.I give permission for attending physician(s) and other medical personnel to administer anyneeded medical treatment, including surgery and, again; I agree to pay for the medicaltreatment. I understand that the child named above or I will be participating in an AirsoftGame.

Medical History

Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.):

Health Insurance Information

Insurance Company: _______________________________________________ Policy Number: ___________________________________________________ Phone Number: ___________________________________________________ Medical Doctor:

___________________________________________________

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Emergency Contacts

Names of persons and telephone numbers to call in case of emergency: ___________________________ _______________________ _____________________

Parent/Guardian Home PhoneWork Phone

___________________________ _______________________ _____________________

Parent/Guardian Home PhoneWork Phone

__________________________ _______________________ _____________________

Other Home PhoneWork Phone

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Agreement for Airsoft Games

I agree to participate in the functions and activities of The Salvation Army, to cooperate withthe leaders and other young people, and to conduct myself as a Christian. I promise torespect God, respect myself, respect other persons, follow the rules of the game and respectproperty. I understand that my continued participation in Salvation Army activities dependson my support of this agreement.

SignatureDate

Adult Participants

As an adult Participant, I hereby agree to each of the consents and waivers listed above,including the Release of Liability, as pertaining to my own participation in functions, activities,special events, and field trips.

________________________________________________ _______________________

SignatureDate

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